DOCSLIB.ORG

CLIA Documentation in the Mohs

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
CLIA Documentation in the Mohs 11/16/2017 2016 Fundamentals of Mohs Surgery San Diego, CA Daniel H. Gong, MS, MSO, C-PM Management Services Officer Clinical Service/Laboratory Manager Daniel H. Gong, MS, MSO, C-PM UC Davis Dermatology, Mohs Laboratories UC Davis Dermatopathology Service No Disclosure of Relevant Relationships with Industry Duplicate CLIA Documentation in the Mohs Lab What is CLIA? y What is CLIA? Types of CLIA labs y Clinical Laboratoryor Improvement Amendments y CLIA Documentation in the Mohs Lab (Established in 1988 by the Federal Government) y Lab Manual- QC Program, Lab Classifications, and y CLIA Regulations: Lab Procedures 1) Establish/follow written polices and procedures y QC Monitors: Temperature, Equipment (Cryostat, Stainer, Refrigerator, Eyewash Station, Fume Hood, Autoclave, Microscope), 2) Take corrective actions, as necessary Service Reports, Reagent and Stain and Corrective Action 3) Review effectiveness of the assessments and y Proficiency Testing Requirements corrective actions taken y Preparing for a CLIA Inspection 4) Revise policies and procedures, as necessary y Guidelines for Counting Tests 5) Communication with staff on assessments y Quality Assessment Process 6) Document all assessment activities Distribute Types of CLIA Labs Lab Procedure Manual 1) Waived – simple tests that do not require additional y The Lab Manual reflects the current practices of the quality assessment (see current list of waived tests) laboratory. http://www.cms.gov/Regulations-and- Guidance/Legislation/CLIA/Downloads/waivetbl.pdf y New procedures and all changes to the Manual must 2) Moderate Complexity – most automated tests that do be approved, signed and dated by the Laboratory not Notmeet the waiver criteria (e.g., KOH exams, fungal Director cultures, and staining procedures) 3) High Complexity – non-automated tests ( e.g., y histopathology, Mohs Surgery) The Lab Director will also review, sign, and date each Do lab manual annually 1 11/16/2017 Lab Procedure Manual 1) Quality Control Program y General Policy – QC program ensures testing/results 1) Quality Control Programs are accurate and in compliance. y Training – Employees trained in QA and QC procedures 2) Laboratory Classification y Documentation – Results of QC analyses will be documented. 3) Laboratory Procedures y Maintenance Checks – Equipment maintained according to protocols. y Corrective Actions – All corrective actions must be documented. Duplicate Temperature Monitors Equipment Monitors y Cryostator QC y Monitor Daily Room Temperature y Stainer QC y Changes in Room Temperature must be documented y Refrigerator QC y Check humidity in the Laboratory y Eyewash Station QC y Fume Hood or Extractor QC y Warmer temperatures requires the Cryostat to work harder y Autoclave QC y Microscope QC CryostatDistribute QC Stainer QC Not Do Specify acceptable ranges 2 11/16/2017 Refrigerator QC Eyewash Station Specify what you are testing Duplicate Fume Hood or Extractor QC orAutoclave QC MicroscopeDistribute QC Slide QC Not Do 3 11/16/2017 Service Reports Service Repair Forms y Yearly Preventative Maintenance (PM) Reports y Equipment Repairs y Service Reports should specify Model/Serial # y Follow up on any PM report recommendations y Ask about equipment recalls Duplicate Reagent and Supplies Reagent Log orOr Lot # The laboratory must define proper storage of reagents and specimens All reagents should have the following on the labels: -identity, titer, concentration, storage requirements, received and open date, initials The laboratory must maintain an inventory to track reagents using a running balance system. Distribute Corrective Actions Corrective Action Form y Written policies and procedures for corrective action must be available and followed as necessary to maintain operations to ensure accurate and reliable test results. y All laboratoriesNot must document all corrective actions taken Do 4 11/16/2017 2) Laboratory Classification 3) Laboratory Procedures y Waived Testing – www.cms.hhs.gov/clia Histopathology in Mohs Surgery is High Complexity y Provider Performed Microscopy (PPM) – e.g, KOH y Principle of Test preparations y Specimen Collection, Rejection, and Handling y Moderate and High Complexity Testing – Mohs Histopathology y Materials, Equipment, and Reagents Used y CLIA Certificates: Waiver, PPM Procedures, y Test Procedure – Sectioning Specimens, H and E Registration, Compliance, and Accreditation Staining of frozen sections y Application for Certification (CMS-116) y Quality Control Analyses – Daily and Random Case Reviews www.cms.hhs.gov/forms/cms116 y Results – Mohs Map and Final Histopathology Report Duplicate Proficiency Testing/Grossing Requirements Preparing for a CLIA Inspection CLIA inspections are performed every two years for y High Complexity Labs (e.g., Mohs Lab): Proficiency moderateor or high complexity lab. testing is a way to verify your lab tests through an external source. Send your cases to a local Common Deficiencies: colleague (minimum twice a year). Incomplete written policies/procedure manuals 1) No formal quality assessment program y Grossing Educational Requirements: Bachelor’s in 2) Maintaining Equipment medical technology, CLS, Chem/Phy/Biological Science. 3) Expired Reagents Associate degree in lab science or medical laboratory education and training equivalent to associate degree: 60 4) Lack of proficiency testing semester hrs – 24 sem hrs of mlt or 24 sem hrs of science 5) Provide documents in organized manner ahead of courses (6hrs each of biology/chemistry and 12 hrs time chem/bio or medical lab technology, or any combination 6) Poor storage of reagents Distribute Guidelines for Counting Tests Quality Assessment Process 1) Assessment Process – What does it include? For histopathology, each block is counted as one test. 2) Frequency of the Review Laboratories that perform special stain on histology 3) Corrective Action Process slides;Not the test volume is determined by adding the number of special stains to total number specimen. For Mohs, each stage counts as one test. Do 5 11/16/2017 Assessment Process Encompasses Frequency of Review 1) All Technical and non-technical functions 1) Establish a schedule or plan for ongoing monitoring 2) All locations/sites where testing is performed 2) The frequency of monitoring will depend on the 3) Interactions with and responsibilities to patients, problem and corrective action taken physicians, other laboratories, and non-laboratory 3) Use the deficiencies and recommendations cited areas or departments of a facility during CLIA surveys for areas to monitor Duplicate Corrective Action Process Commonor Deficiencies in CLIA Inspections 1) Identification of the problem y Clearly defined temperature ranges 2) Resolution of the problem y Acceptable temperature ranges 3) New polices that will prevent recurrence y Regular review of temperatures and noted actions 4) Communication of written polices and the action when temperature is out of range. taken to prevent future problems y QC for stains 5) Monitor corrective actions y How often are you changing your stains 6) Include personnel and staff in the review process 7) Document! Document! Document! Distribute References Conclusion CLIA Regulations/Laws http://www.ecfr.gov/cgi-bin/text- CLIA Survey Documentation Focus: idx?SID=1248e3189da5e5f936e55315402bc38b&node=pt42.5.493&rgn=div5 http://www.gpo.gov/fdsys/pkg/USCODE-2011-title42/pdf/USCODE-2011-title42- 1) Procedure manual chap6A-subchapII-partF-subpart2-sec263a.pdf 2) Personnel Records (e.g., training and experience, American Academy of Dermatology Clinical Laboratory competencyNot assessment) Improvement Amendments (CLIA) for Dermatology 3) QC records (e.g., calibration records, instrument maintenance Interpretative guidelines for CLIA surveys 4) Quality Assessment Plan and Documentation https://www.cms.gov/Regulations-and- Do Guidance/Legislation/CLIA/Interpretive_Guidelines_for_Laboratories.html 6 Duplicate or Thank You [email protected] Distribute Not 11/16/2017 Do 7.
Load more

Recommended publications
  • Preparing Sodium Hydroxide Solutions Nov 2016
    STANDARD OPERATING PROCEDURE: Preparing sodium hydroxide solutions Note: To be undertaken only by trained personnel in conjunction with a current Safety Data Sheet (SDS) and site-specific risk assessment. ___________________ 1. Introduction Sodium hydroxide (NaOH) is a hazardous chemical and must be treated with care. It is highly corrosive to skin and eyes and extremely toxic if ingested. The solid can be purchased as pellets, flakes or mini pearls. It is very hygroscopic (absorbs water from the air) and will also absorb carbon dioxide from the air and therefore cannot be used as a primary standard for titrations. To minimise its absorption of water and carbon dioxide, it should be kept in a tightly closed container and left open for as little time as possible. Dissolving sodium hydroxide in water is an exothermic (heat producing) reaction. Synonyms: caustic soda, lye, soda lye. 2. Context These instructions are for the use of experienced teachers and technicians only. Do not make up a solution for the first time without seeking practical advice from an experienced colleague. 3. Safety Notes This activity may only be carried out with appropriate facilities available i.e. running water, chemical safety/eyewash station and relevant Personal Protective Equipment (PPE) Conduct procedure in a well-ventilated area or fume cupboard. Avoid contact with skin and eyes, and avoid breathing fumes. The preparation of sodium hydroxide solutions liberates heat and may produce caustic fumes/vapours. Ensure that glassware is free from chips and cracks before use. For first aid, accident and spill procedures refer to SDS before making a solution.
    [Show full text]
  • Biosafety Level 2 Guide University of Illinois at Urbana-Champaign
    Biosafety Level 2 Guide University of Illinois at Urbana-Champaign Table of Contents Introduction .................................................................................................................................................. 2 Risk Assessments .......................................................................................................................................... 2 Routes of Exposure ................................................................................................................................... 3 Risk Groups and Biosafety Levels .............................................................................................................. 4 IBC Registrations ....................................................................................................................................... 5 Laboratory Audits...................................................................................................................................... 5 Risk Assessment Scenarios ........................................................................................................................ 5 Training requirements .................................................................................................................................. 7 Introduction to Biosafety .......................................................................................................................... 7 NIH Guidelines Overview .........................................................................................................................
    [Show full text]
  • Reservoir Fluid Properties
    Komar University of Science and Technology PTE 3315C Reservoir Fluid Properties LABORATORY MANUAL December 2015 CONTENTS 1 1. Laboratory Safety…………………………………………………….……... 2 1.1. The principle of Safety 2 1.2. First Aid 3 1.3. Laboratory Practice2 3 2. Liquid density..………………………………………………………………… 4 2.1. Definitions 4 2.2. Measurement of density 4 2.3. Experiments 5 3.3.1. Fluid density using the pycnometer (Exp.1) 5 3. Viscosity……...………………………………………………………….……... 7 3.1 Definitions 7 3.2 Effect of pressure and temperature on viscosity 8 3.3 Method for measuring viscosity 8 4.1.1. Capillary type viscometer 8 4.1.2. Falling ball viscometer 9 4.1.3. Rotational viscometer 10 3.4 Experiments 12 4.1.4. Liquid viscosity measurement using capillary type 12 viscometer (Exp. 2) 4. Surface and interfacial tension..……………………………………….……... 15 4.1. Definition 15 4.2. Methods of interfacial tension measurements 16 4.2.1. Capillary rise method 16 4.2.2. Wilhelmy plate method 17 4.2.3. Ring method 17 4.2.4. Drop weight method 18 4.2.5. Pendant drop method 19 4.2.6. Spinning drop method 21 4.3. Experiments 21 4.3.1. Interfacial tension (IFT) measurement, 21 pendant drop method (Exp. 3) 4.3.2. Measurement of IFT with the ring tensiometer (Exp. 4) 23 Page | 1 1 LABORATORY SAFETY 1.1. THE PRINCIPLES OF SAFETY The main principles of safety in the lab to be considered are: 1 Safety Program 2 Be concerned about the safety of others 3 Understand the hazards associated with your particular experiment 4 Know what to do in an emergency 5 Report hazards or hazardous conditions 1.1.1.
    [Show full text]
  • Guide to Laboratory Safety (Chemical Hygiene Plan)
    Thomas Jefferson University Guide to Laboratory Safety (Chemical Hygiene Plan) Developed by: Thomas Jefferson University Department of Environmental Health and Safety In conjunction with: The Laboratory Safety Committee Of the University Safety Committee Thomas Jefferson University Updated 2013 Review Verification Form This Guide to Laboratory Safety has been developed by the Department of Environmental Health and Safety at Thomas Jefferson University to serve as the Chemical Hygiene Plan required by the Occupational Safety and Health Administration’s (OSHA) Laboratory Standard promulgated in 1990. The intention is to provide guidelines and procedures to everyone associated with laboratories and laboratory related activities. Annual Chemical Safety Review Verification by Environmental Health Officer Verification Date Signature 2013 2014 2015 2016 2017 Annual Biosafety Review Verification by Biosafety Officer Verification Date Signature 2013 2014 2015 2016 2017 Annual Overall Review Verification by Director of Environmental Health and Safety Verification Date Signature 2013 2014 2015 2016 2017 Preface The Guide to Laboratory Safety has been developed at Thomas Jefferson University (Jefferson) as the Chemical Hygiene Plan required by the Occupational Safety and Health Administration (OSHA) Laboratory Standard promulgated in 1990. The intention is to provide guidelines and procedures to everyone associated with laboratories and laboratory related activities. The goal is to create and encourage a safer work environment. This laboratory guide can be used as a valuable resource in answering the concerns of employees and students who work and train at Jefferson. Laboratory employees and students are expected to work and act in a safe, professional manner, implementing the information contained in this guide. Safety awareness and practices then become valuable assets that are taken to any workplace, making research, clinics, and hospitals safer working environments for everyone.
    [Show full text]
  • Isolation of Amoebae and Pseudomonas and Legionella Spp
    APPLIED AND ENVIRONMENTAL MICROBIOLOGY, Jan. 1991, p. 163-167 Vol. 57, No. 1 0099-2240/91/010163-05$02.00/0 Copyright C) 1991, American Society for Microbiology Isolation of Amoebae and Pseudomonas and Legionella spp. from Eyewash Stations CHRISTINE PASZKO-KOLVA,1 HIROYUKI YAMAMOTO,'t MANOUCHEHR SHAHAMAT,1 THOMAS K. SAWYER,2 GARY MORRIS,3 AND RITA R. COLWELL'* Department of Microbiology' and Department of Environmental Safety,3 University of Maryland, College Park, Maryland 20742, and Rescon Associates Inc., Royal Oak, Maryland 216622 Received 23 August 1990/Accepted 25 October 1990 Forty eyewash units were sampled for protozoa, bacteria, and fungi. Total heterotrophic bacterial counts on nutrient agar and R2A agar (Difco Laboratories, Detroit, Mich.) ranged from 0 to 105 CFU/ml, with Pseudomonas spp. being the most frequently isolated. Total counts of 104 and 108 cells per ml were obtained with the acridine orange staining procedure. All samples were examined for Legionella spp. by direct fluorescent-antibody staining and by culturing on buffered charcoal-yeast extract agar containing a-ketoglu- tarate and glycine and supplemented with cycloheximide, vancomycin, and polymyxin B. DNA-DNA hybridization was used to confirm identification of the Legionella isolates. Legionellae were detected in 35 of 40 (87.5%) samples by direct fluorescent-antibody staining, with 3 samples yielding both Legionella spp. and amoebae. Amoebae identified as Hartmannella, Vahlkampfia, Acanthamoeba, and Cochliopodium spp. were detected in 19 of 40 (47.5%) samples. Sabouraud dextrose agar was used to obtain a crude estimate of viable fungal populations. pH, hardness, and ammonia, alkalinity, chlorine, copper, and iron contents were recorded for all water samples collected from eyewash stations; 33% of the samples had .10 mg of CO2 per liter.
    [Show full text]
  • BMBL) Quickly Became the Cornerstone of Biosafety Practice and Policy in the United States Upon First Publication in 1984
    Biosafety in Microbiological and Biomedical Laboratories 5th Edition U.S. Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institutes of Health HHS Publication No. (CDC) 21-1112 Revised December 2009 Foreword Biosafety in Microbiological and Biomedical Laboratories (BMBL) quickly became the cornerstone of biosafety practice and policy in the United States upon first publication in 1984. Historically, the information in this publication has been advisory is nature even though legislation and regulation, in some circumstances, have overtaken it and made compliance with the guidance provided mandatory. We wish to emphasize that the 5th edition of the BMBL remains an advisory document recommending best practices for the safe conduct of work in biomedical and clinical laboratories from a biosafety perspective, and is not intended as a regulatory document though we recognize that it will be used that way by some. This edition of the BMBL includes additional sections, expanded sections on the principles and practices of biosafety and risk assessment; and revised agent summary statements and appendices. We worked to harmonize the recommendations included in this edition with guidance issued and regulations promulgated by other federal agencies. Wherever possible, we clarified both the language and intent of the information provided. The events of September 11, 2001, and the anthrax attacks in October of that year re-shaped and changed, forever, the way we manage and conduct work
    [Show full text]
  • Osmium Tetroxide
    Date: 08/08/2011 Effective: 08/08/2012 SOP Number: 0081 Review Date: 08/08/2013 Developed By: University Department of Environmental Health and Safety Standard Operating Procedures For Handling, Storage and Disposal of Osmium Tetroxide Purpose The purpose of this document is to establish specific standard operating procedures for handling, storage, and disposal of Osmium Tetroxide. The requirements established in this SOP are in conjunction with the University’s Chemical Hygiene Plan. Overview Osmium Tetroxide, an intermediate of osmium ore refining, is an inorganic compound that is highly toxic, even at low exposure levels and must be properly handled at all times. Low concentrations, even below those that may be smelled (about 2ppm), can lead to pulmonary edema and subsequent death when inhaled. Other symptoms of inhalation include coughing, headaches, irritation of the respiratory tract, wheezing, shortness of breath, and visual disturbances. Additional care must be used as this compound readily sublimates. It may take hours after exposure for any noticeable symptoms to appear. Osmium tetroxide is also a strong oxidant and corrosive, capable of burning and blistering human tissues. Osmium tetroxide may also stain the cornea, leading to potential blindness. Despite the relative scarcity of osmium, osmium tetroxide has a number of uses, including: Biological staining, Organic synthesis, Polymer staining, and as an adduct of buckminsterfullerene. Despite its expense, osmium tetroxide has the potential to be used as a chemical weapon and is believed to have been used in at least one failed plot. Standard Operating Procedures Handling 1. The Material Safety Data Sheet and this SOP must be reviewed before use of osmium tetroxide in the laboratory.
    [Show full text]
  • Safety in the Chemistry Laboratory
    Reference: Safety in Academic Chemistry Laboratories-Accident Prevention for College and University Students. A Publication of American Chemical Society Joint Board-Council Committee on Chemical Safety. 7th Edition-Vol 1 Safety in the Chemistry Laboratory General • All students must pass the Safety Quiz and sign a Safety Agreement before working in the lab. • State and Federal law require the use of splash proof safety goggles by anyone working in a chemical lab. No student will be allowed to work in the lab or weighing room without wearing the department approved splash-proof safety goggles with side shield, lab apron/coat, and closed toe shoes. There will be no exception to this rule. • You will be doing lab experiments that require hazardous chemicals. To ensure a safe chemistry lab you need to follow : o all safety rules given , o the safety DVD, and o all written and verbal instructions given for each experiment. • All safety rules will be strictly enforced. Ignoring or failing to follow any safety rule or instruction will result in your being dismissed from the lab. Safety Equipment Know the locations/operations and use of the following emergency equipments: 1. Fire extinguisher is stored in a compartment attached to the wall. 2. Red fire alarm is on the wall at eyelevel next to the fire extinguisher 3. Fire blanket is stored inside a labeled red box attached to the wall next to the fire extinguisher. The blanket is to be used on clothing that caught fire. The blanket can also be used to cover a shock victim. 4.
    [Show full text]
  • Pyrophoric Handling Procedure
    Pyrophoric Handling Procedure Carnegie Mellon Environmental Health & Safety 5000 Forbes Avenue FMS Building, 3rd Floor Pittsburgh, PA 15213 412-268‐8182 www.cmu.edu.ehs October 2019 TABLE OF CONTENTS Introduction ........................................................................................................................................3 Examples of Pyrophoric/Water Reactive Materials ...........................................................................3 Hazards ..............................................................................................................................................3 Controlling the Hazards .....................................................................................................................3 Personal Protective Equipment (PPE) ...............................................................................................4 Eye Protection ........................................................................................................................4 Skin Protection .......................................................................................................................4 Eyewash/Safety Showers .......................................................................................................4 Fume Hood.............................................................................................................................4 Glove (dry) box ......................................................................................................................5
    [Show full text]
  • Laboratory Biosafety Manual Third Edition
    Laboratory biosafety manual Third edition World Health Organization Geneva 2004 WHO Library Cataloguing-in-Publication Data World Health Organization. Laboratory biosafety manual. – 3rd ed. 1.Containment of biohazards - methods 2.Laboratories - standards 3.Laboratory infection - prevention and control 4.Manuals I.Title. ISBN 92 4 154650 6 (LC/NLM classification: QY 25) WHO/CDS/CSR/LYO/2004.11 This publication was supported by Grant/Cooperative Agreement Number U50/CCU012445-08 from the Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. © World Health Organization 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.
    [Show full text]
  • Location of Training Records and Guidelines Location of Safety
    Lab Operations Checklist Lab(s): Room 317, 311 SSMB, College of Charleston Date Training Initiated: PI Name: Pam Riggs‐Gelasco Student Name: Student ID # Activity Description Student Date PI Mandatory initials complet‐ initials regardless of ed project Safety and Location of safety shower, eyewash, fire extinguisher, first aid kit, safety Industrial glasses, lab coat rack, MSDS sheets, spill kit, emergency contact X Hygiene information, updated lab cell phone list General departmental research training completion X Incident reporting guidelines and procedures X Monthly lab safety review and record‐keeping procedure X Policy for hand washing prior to eating X Policy for gloves wearing, when to take off gloves, what to touch with gloves on (with special note about the Gel Doc area, for which gloves are mandatory). No gloves on door knobs or phones. Not all gloves offer X equal protection; select proper gloves type for your particular experiment. Location of training records and guidelines X Environ‐ Waste disposal guidelines, especially for ethidium bromide, acrylamide, X mental and bacterial cultures Biohazard waste disposal procedure X Spill clean‐up kit location and procedure X Lab check list Both gas valves are off, and Bunsen burner valves are off. X before leaving lab each day X Fridges, freezers, ‐80, incubators, shakers, and centrifuges are all closed. Equipment used in 311 is secured, cleaned, and your own items returned to our lab: Autoclave, Sorvall centrifuge, Eppendorf centrifuge, X UV‐vis, PCR machine, MilliQ water system, etc. Temperature‐sensitive reagents and samples are properly incubated or X refrigerated or frozen according to their needs. Room‐temperature chemicals, pipet tip boxes and other sterile supplies, etc.
    [Show full text]
  • Laboratory Inspection Checklist
    RICE UNIVERSITY Environmental Health and Safety Laboratory Inspection Checklist Electrical Safety: Relocate electrical cords (that present tripping hazards) or are pinched by door or other objects. Cords must not cross walk areas unless they are taped or‐fastened securely to the floor and must not run under doors or cabinets. Install permanent wiring. Do not use extension cords as permanent wiring. If permanent wiring is impossible use an electrical power surge strip with a fuse or circuit breaker. Repair damaged electrical cords/outlets/plugs (pinched, cracked, burnt). Discontinue use of plugs without ground prongs. Discontinue use of three‐way plugs. Remove extension cords above ceiling tiles Electrical panel and disconnects is accessible and labeled. Do not connect two or more extension cords, power strips, or combination to gain additional outlets or length. (Daisy chaining extension cords). Fire/Life Safety: Keep lab door closed and latched. Reduces spread of fire/ smoke/ fugitive odors. Remove any obstructions blocking fire extinguisher and/or pull station. Keep evacuation exit routes clear. Fire extinguisher: Missing/ needs mounting/ needs service. EHS will take care of these issues. Replace missing ceiling tiles. Ceiling tiles are part of the‐fire break and ventilation system. EHS will issue a work order if replacement is necessary. Replace damaged/cracked tubing. Remove items that are stored within 18 inches of ceiling if room contains smoke detector or sprinklers. Fume Hoods / Biological Safety Cabinet Hoods have to be inspected within three years, and be in working order. Remove clutter in hood. Clutter in a hood prevents a spill/splash hazard and can interfere with the airflow.
    [Show full text]